Treatment of refractory status epilepticus with hemispherectomy.
A 7-year-old boy with left hemiparesis secondary to right hemispheric cortical dysplasia was admitted to the hospital with increasing numbers of seizures. Magnetic resonance imaging showed a small dysplastic right hemisphere with abnormally thickened gyri and an apparently normal left hemisphere. Previous video-electroencephalogram (EEG) monitoring showed bilateral independent spikes and generalized slow spike-and-wave episodes on EEG and [18F]fluorodeoxyglucose (FDG) positron emission tomography scan demonstrated scattered areas of regional hypometabolism bilaterally; therefore hemispherectomy was not undertaken at that time. During this hospital stay, nonconvulsive status epilepticus developed and was refractory to multiple medical therapies including pentobarbital (PTB) coma. Burst-suppression pattern during PTB coma appeared to be generalized spike and wave, but when EEG was reviewed with increased time resolution spikes suggested a right hemisphere origin. The patient underwent bilateral intracarotid amobarbital spike-suppression test that showed only minimal suppression of epileptiform discharges with injection of the left carotid, but complete suppression of spike activity after right-sided carotid injection. A right hemispherectomy was performed with complete cessation of status epilepticus. Postoperative EEG showed no epileptiform discharges. Patient follow-up was limited to 12 months after surgery. The patient had regained the ability to walk unaided and was seizure free with a single antiepileptic medication. This case illustrates a potentially life-saving procedure for refractory status epilepticus and several techniques including a spike-suppression test to aid in prediction of cessation of seizures after hemispherectomy.
Division of Child Neurology, Children's Health Center, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA. dduane@chw.edu
Dawn C
DC
Duane
Yu-tze
YT
Ng
Harold L
HL
Rekate
Steve
S
Chung
John B
JB
Bodensteiner
John F
JF
Kerrigan
D000654:Amobarbital / Q000494:pharmacology; D001931:Brain Mapping / Q000379:methods; D002648:Child; D004569:Electroencephalography / Q000187:drug effects; D019788:Fluorodeoxyglucose F18; D007839:Functional Laterality / Q000187:drug effects / Q000502:physiology; D038421:Hemispherectomy / Q000379:methods*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D011300:Preoperative Care; D013226:Status Epilepticus / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery*; D014055:Tomography, Emission-Computed; D016896:Treatment Outcome
D019788:Fluorodeoxyglucose F18; D000654:Amobarbital