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Intractable epilepsy due to postnatal MCA stroke Mariam S. Aboian Mayo Medical School
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J.V. is 34 yr R-h M ✤ Cerebral Palsy due to Right MCA stroke after birth; term delivery ✤ simple and complex partial sz starting at 5 months ✤ Status epilepticus (2) ✤ failed 10 AEDs
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Exam ✤ Left spastic hemiparesis, able to walk CN normal Strength and Tone 5/5 on right side Strength and Tone 2/5 LUE and 4/5 LLE
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Sz focus Mapping ✤ Sz semiology - EMU monitoring right frontal onset - limited flexion of left arm (1) left leg is tonically extended (2) turning to the left (2) beginning of seizure head turns to the left (2) bicycle type movements (frontal focus)
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Sz focus Mapping ✤ Scalp EEG - EMU monitoring interictal theta slowing over R hemisphere 2 interpretable seizures 3-4 Hz ictal epileptiform discharges is either generalized w/ R>L or right-sided
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Sz focus Mapping - PET ✤ Hypometabolism in R orbital frontal region, R anterior and superior temporal lobe R occipital pole R basal ganglia and thalamus
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Pre-op MRI Hypo-intense non-enhancing R frontoparietal and temporal lobe, R thalamus, ant limb of R internal capsule, R caudate nucleus, R cerebral peduncle, R pons and medulla
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Operative Set-up
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Dysplastic Brain with cystic changes
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Intra-op Motor Mapping Functional MRI: negative
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Step 1: Temporal Lobectomy
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Step 2: Frontal Lobectomy
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Step 3: Occipital Lobectomy
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Step 4: Hippocampus dissection
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Step 5: Closure
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Postnatal stroke and epilepsy ✤ 1:4,000 of term infants w/ stroke (deVeber et al, 2000) ✤ neuronal apoptosis is prevalent in postnatal synaptogenesis period (Vexler and Yenari, 2009) ✤ deVries et al, Neuropediatrics, 1997 7 w/ main branch involvement: hemiplegia (7/7), epilepsy (2/7) ✤ McClelland and Maxwell, Ann Neurol, 2007 9 adults (>18 yrs) w/ hemiplegia and unilat visual field loss; 5 seizure free >30 yr follow up
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Acknowledgements Dr. A. Eskandar Dr. M. Simon Tara Jennings Sub-Is: Nelson and Akin Residents: Dr. J. Gerrard, Dr. G. Dunn Dr. J. Gale Harvard Medical School and MGH Mayo Medical School
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