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Case of the Month

Welcome to CNS Case of the Month Section.
The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.

We are always open to suggestions, and if you have a case or questions that you would like to have presented, please submit them to: info@1cns.org

Brian L. Hoh, MD
University of Florida
Ashok R. Asthagiri, MD
Associate Professor
Department of Neurological Surgery
University of Virginia
Maryam Rahman, MD MS
Assistant Professor
Department of Neurosurgery
University of Florida
Alexander A. Khalessi MD, MS
University of California San Diego
Wilson Z. Ray, MD
Assistant Professor in Neurosurgery
Department of Neurological Surgery
Washington University School of Medicine
Edward R. Smith, MD
Director, Pediatric Cerebrovascular Surgery
Department of Neurosurgery
Children's Hospital Boston / Harvard Medical School
Sameer Sheth, MD, PhD
Assistant Professor of Neurosurgery
Columbia University Medical Center
New York Presbyterian Hospital
 
April 2014: Mesial Temporal Sclerosis

H&P

  • 35-year-old male baseball stadium guard with epilepsy
  • Currently AED regimen: levetiracetam, lacosamide
  • Previous AEDs tried: phenytoin, lamotrigine, carbamazepine
  • Continues to have 2-3 complex partial seizures per month
  • Seizure semiology: feeling of foreboding followed by loss of awareness
  • Video-EEG: right anterior temporal seizures
  • MRI and PET scan shown in figure
  • Neuropsychological testing: Full-scale IQ 80, verbal memory average

Figure 1:
[Click to view larger image]
Click image to view larger picture.

1. What is the next step in management?
    a. Add clobazam to the medication regimen
    b. Perform Wada test
    c. Perform intracranial recordings focused on the right temporal lobe
    d. Perform standard right anterior temporal lobectomy
    e. Perform right selective amygdalohippocampectomy
2. What is the chance that adding another medication to the patient’s regimen will reduce seizure frequency?
    a. 0-5%
    b. 10-15%
    c. 20-25%
    d. 30-35%
    e. 40-45%
3. When you decide to intervene surgically on a patient with classic mesial temporal sclerosis, which technique do you prefer?
    a. Stereotactic radiosurgery
    b. Laser ablation with MR thermography
    c. Anterolateral resection with amygdalohippocampectomy
    d. Selective amygdalohippocampectomy
    e. Focused ultrasound ablation
4. Which of the following describes you?
    a.   Resident/fellow
    b.   Private practice
    c.   Academics
5. I practice in one of the following locations.
    a.   I practice in one of the following states: WA, OR, CA, AK, HI
    b.   I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
    c.   I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
    d.   I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
    e.   I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
    f.   I practice in Mexico or Canada
    g.   I practice in South America
    h.   I practice in Europe
    i.   I practice in Asia
    j.   I practice in Australia/Pacific Rim
    k.   I practice in Africa
6. Comments
   

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Pubmed References
  • Rees JH. Paraneoplastic syndromes: when to suspect, how to confirm, and how to manage. J Neurol Neurosurg Psychiatry. 2004 Jun;75 Suppl 2:ii43-50.

  • Richard AC Hughes, David R CornblathGuillain-Barré syndrome. The Lancet, Volume 366, Issue 9497, Pages 1653-1666