037 - Stereo-electroencephalography (sEEG) and MRI–guided laser ablation in drug-resistant epilepsy with a broad epileptogenic network: case report.
Monday, April 28, 2025
7:00am – 9:15am HST
Publication Number: 37.6972
Luisa Fernanda Atunes Ortega, Boston Children's Hospital, boston, MA, United States; Tobias Loddenkemper, Boston Children's Hospital, Boston, MA, United States; Scellig Stone, Boston Children's Hospital, Boston, MA, United States; Michelle Chiu, Harvard Medical School, Boston, MA, United States
Research Fellow Boston Children's Hospital Boston, Massachusetts, United States
Background: Stereo-electroencephalography (sEEG) and MR-guided laser interstitial thermal therapy (Mg-LITT) are minimally-invasive surgical procedures for evaluating and treating drug-resistant epilepsy (DRE). Their efficacy and safety in focal epilepsy is well-established, while their application in patients with broad epileptogenic networks is less clear. Objective: Indentify the role of sEEG and Mg-LITT in patients with focal and DRE with generalized features. Design/Methods: Presentation of a patient with non-lesional DRE with multifocal and generalized findings on phase I evaluation, who underwent sEEG followed by Mg-LITT of active nodes within his epileptogenic network, with resultant seizure freedom. Results: We present a 14-year-old male with onset of epilepsy at 6 years. He had multiple seizure types including focal seizures with déjà vu, visual auras, and/or impaired awareness, as well as nocturnal generalized tonic-clonic seizures. MRI did not identify a seizure focus. He trialed 5 anti-seizure medications but continued to have 2-3 seizures per week prior to surgical intervention.
Phase I EEG recorded generalized and multifocal sharp waves (right and left temporal, left occipital, left temporo-occipital). Auras of déjà vu and abnormal sensation correlated with left posterior temporal or temporo-occipital seizures, while staring spells were associated with generalized attenuation and fast activity with maximal evolution in the left hemisphere. Magnetoencephalography implicated left temporal/parietal areas. Positron emission tomography showed decreased uptake in bi-temporal lobes. Functional MRI revealed left dominant language, and transcranial magnetic stimulation showed normal contralateral motor distribution. Neuropsychological testing showed average cognitive ability and non-lateralizing/localizing findings.
He underwent sEEG with 17 electrodes sampling left temporal, parietal, and occipital lobes and insula. Multiple electroclinical seizures were recorded with onset from the left medial temporal-parietal-occipital lobe. He underwent an MR-guided LITT of the most active nodes in his seizure network, including foci in the mid-posterior left occipitotemporal gyrus, inferior-posterior precuneus, anterior lingual gyrus, and mid-posterior insula. Seizures eventually waned, ASMs were weaned off, and he was seizure free for 2 years at time of last follow-up.
Conclusion(s): sEEG has the potential of identifying active nodes within a broad epileptogenic network, and targeted LITT of these nodes may sufficiently disrupt the network and result in favorable seizure outcomes while leaving eloquent cortex intact.
