Abstract:
Background. Temporal lobe epilepsy (TLE) is the most common form of focal epilepsy.
Approximately 6 out of 10 patients with focal epilepsy have TLE. Hippocampal sclerosis (HS)
is a frequent pathological abnormality underlying the TLE.
Case report. A 34-year-old man was admitted to the epileptology clinic with seizure episodes
that start focally with an unpleasant feeling in the stomach, unusual smells, unmotivated fear
followed by repetitive jerky movements of the left part of body and complex automatic
behavior, accompanied with altered consciousness, which periodically progressed to a bilateral
tonic-clonic seizure. The postictal period was characterized by confusion and amnesia. The
seizures started at the age of 12 years after a traumatic brain injury. Carbamazepine, valproic
acid, and clonazepam have been used (in monotherapy or polytherapy) to treat seizures,
however, with inadequate response. His video electroencephalogram (EEG) monitoring
revealed focal right temporo-frontal epileptiform discharges (spike, sharp wave, sharp and
slow-wave) in wakefulness; right temporal, temporo-frontal epileptiform discharges in
drowsiness and slow sleep. The high-density EEG (256 channels) revealed the onset of
epileptiform activity in the hippocampus (parahippocampal gyrus) with subsequent
propagation to the temporal lobe (superior temporal gyrus). MRI scan showed that the inferior
horn of the right lateral ventricle measured 5.0 mm (left 1.5 mm) and the right hippocampus
had a reduced volume. After the neurological evaluation, patient was started on carbamazepine
extended release (15 mg/kg/bid), lamotrigine (3.5 mg/kg/bid) and clonazepam 1 mg/qd. With
this combination of drugs, his seizures are partially controlled.
Conclusions. Seizure semiology, video-EEG, high-density EEG, and MRI results confirm the
diagnosis of TLE with HS. Taking into account the inadequate control of seizures with
medication and the presence of a confirmed structural cause, the patient could be considered
eligible for the pre-surgical evaluation. TLE with HS is refractory for treatment in as many as
60% to 80% of cases. However, with the aid of MRI, high-density EEG, and
neuropsychological evaluation, patients can now be timely selected for a surgical resection, a
procedure that leads to seizure control and improvement in disabling psychiatric symptoms
with minimal need for medication. Studies show a better long-term outcome in patients with
HS after surgery (up to 90%) in comparison with antiepileptic drug therapy.
Description:
Academy of Sciences of the Republic of Moldova, Neurology Department, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, The 8th International Medical Congress for Students and Young Doctors, September 24-26, 2020