Medical Student Oregon Health & Science University
Rationale: Surgical resection, laser interstitial thermal therapy (LITT), and neurostimulation modalities are all surgical options for patients with medically-refractory focal epilepsy, but little is known about performing them concurrently (or in close succession). In complex cases where patients have an epileptogenic zone that overlaps with eloquent cortex, or in patients with multifocal seizure onset zones with a predominant focus amenable to surgery, combination therapy may offer a useful and effective option for surgical treatment. The purpose of this case series was to highlight four combination epilepsy surgery cases and their outcomes. Methods: Systematic review of our Redcap epilepsy surgery database was performed, reviewing epilepsy surgery cases completed at our institution since 2015, identifying four cases where combination surgical therapy was used. All four patients underwent some form of staged combined therapy, including LITT, responsive neurostimulation (RNS), resection, and deep brain stimulation (DBS). Results: Patient 1 had a previous left temporal lobectomy at an outside hospital (1996). At our institution, she underwent LITT of residual left hippocampus followed by RNS implant with electrode placement over the left middle/superior temporal and parietal regions. 10 months post-surgery she is free of seizures that impair awareness (previously weekly) and has a >50% reduction in auras. Patient 2 had right temporal lobectomy followed with RNS placement with electrodes targeting the right insula and Heschl’s area. 14 months post-operatively, she is free of seizures that impair consciousness, but continues to have auditory auras 2-3 times per month. Patient 3 had prior VNS placement (2012) with minimal improvement. She underwent LITT on bilateral inferior periventricular nodules followed by placement of RNS electrodes targeting the left lateral periventricular nodule and right hippocampus. An unexpected surgical complication was an incomplete L>R bilateral superior quadrant visual field cut. She is seizure-free 11-months postoperatively. Patient 4 underwent LITT of two known focal cortical dysplasias (FCDs) in the right frontal lobe and right temporal pole followed by DBS placement targeting the anterior nucleus of the thalamus. She is seizure-free 6-month postoperatively. Table 1 includes additional patient data on seizure frequencies, pre-surgery workup and perioperative period.
Conclusions: This case series demonstrates that performing multiple surgical modalities in close succession is a viable option for complex medically-refractory focal epilepsy patients. Two of four patients became seizure free after surgery and the other two patients became free of disabling seizures after surgery but continued to have auras with reduced frequency. Funding: Please list any funding that was received in support of this abstract.: None Click here to view image/table
