Abstract
BACKGROUNDThe reevaluation and management of seizure relapse following resective surgery in magnetic resonance imaging (MRI)-negative pharmacoresistant epilepsy remains a significant challenge.OBSERVATIONSA 25-year-old right-handed male with medically refractory epilepsy presented with nonlocalizing electroencephalography (EEG) and MRI. Stereo-EEG (SEEG) implantation based on semiology and positron emission tomography imaging revealed a left frontal opercular focus with rapid bilateral insular ictal synchrony. The initial epileptogenic zone was resected and pathologically proven to be type 2A focal cortical dysplasia (FCD). Seizure relapse after 9 months was eventually reinvestigated, and repeat SEEG revealed a secondary epileptogenic focus in the contralateral insula. A novel technique of volumetric stereotactic radiofrequency ablation (vRFA) was utilized for the right insular focus, following which, the patient remains seizure-free for 20 months. He suffered a transient bilateral opercular syndrome following the second intervention that eventually resolved.LESSONSThe authors present clinical evidence to suggest epileptogenic nodes distant from the primary focus as a mechanism for seizure relapse following FCD surgery and the importance of bilateral insular SEEG coverage. The authors also describe a novel technique of minimally invasive vRFA that allows ablation of a larger volume of cerebral cortex when compared to conventional bedside SEEG electrode thermocoagulation.
Highlights
The reevaluation and management of seizure relapse following resective surgery in magnetic resonance imaging (MRI)-negative pharmacoresistant epilepsy remains a significant challenge
We report a patient with a left frontal opercular type 2 focal cortical dysplasia (FCD) studied initially with bilateral stereoelectroencephalography (SEEG) who developed a seizure relapse in the first year after surgical removal of the FCD
We describe the use of a novel technique of minimally invasive robotic-assisted stereotactic radiofrequency ablation (RFA) of the contralateral epileptogenic focus responsible for seizure relapse
Summary
The reevaluation and management of seizure relapse following resective surgery in magnetic resonance imaging (MRI)-negative pharmacoresistant epilepsy remains a significant challenge. A novel technique of volumetric stereotactic radiofrequency ablation (vRFA) was utilized for the right insular focus, following which, the patient remains seizure-free for 20 months. He suffered a transient bilateral opercular syndrome following the second intervention that eventually resolved. We report a patient with a left frontal opercular type 2 focal cortical dysplasia (FCD) studied initially with bilateral stereoelectroencephalography (SEEG) who developed a seizure relapse in the first year after surgical removal of the FCD. On review of the initial SEEG, there was evidence of bilateral insular epileptogenicity, which was reconfirmed on further extensive SEEG upon relapse This supports the existence of an independent epileptogenicity distant from a primary focus as a mechanism for seizure relapse after FCD surgery. We describe the use of a novel technique of minimally invasive robotic-assisted stereotactic radiofrequency ablation (RFA) of the contralateral epileptogenic focus responsible for seizure relapse
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