A patient with drug-resistant epilepsy who showed seizure freedom after hemorrhage related to radiation-induced cavernous malformation

Abstract

We present a case of seizure freedom after spontaneous hemorrhage of the epileptic focus. A 47-year-old male patient, who has had focal tonic seizures since age 13, suffered from drug-resistant epilepsy presenting as 3~5 episodes of seizures every day. As the MRI showed a cystic mass at right insular cortex, he underwent gamma-knife surgery 17 years ago but the seizure frequency was not reduced. After surgery, he had a small, slowly-growing hemorrhagic residue in the right insula, which was considered as radiation-induced cavernous malformation. The patient had been given over 14 anti-epileptic drugs (AEDs); however, the seizures were not stopped. Suddenly, he reported seizure freedom for over 4 months with the same AEDs treatment. His follow-up MRI showed acute bleeding of pre-existing cavernous malformation at right insular area, while the patient did not show any neurologic deficit. Craniotomy with removal of hemorrhage was done, and seizure freedom maintained even after levetiracetam and phenobarbital were tapered out. This demonstrates a rare case of self-destruction of epileptic focus due to hemorrhage. Figure :(A) At first visit, 17 years ago, T2 MRI showed 1.5cm-sized cystic mass lesion in right insular cortex. (B) After gamma-knife surgery, a small radiation-induced cavernous malformation was seen. (C) When patient reported seizure freedom for over 4 months, acute bleeding of pre-existing cavernous malformation at right frontal lobe was noted, with 3cm-sized hematoma formation at right striatocapsule region. (D) After craniotomy, MRI showed residual edema in right hemisphere.