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Aaron A. Cohen-Gadol, Jacqueline A. Leavitt, James J. Lynch, W. Richard Marsh, and Gregory D. Cascino

T he number of patients with epilepsy who are eligible for surgical treatment has increased in the past decade. Amygdalohippocampectomy with or without ATL is considered the standard surgical treatment for medically refractory epilepsy originating from the mesial temporal lobe structures. 26 The success rate as defined by a significant reduction in seizures occurs in up to 80% of patients with low perioperative morbidity. 3, 4, 7 Diplopia is a potential neuroophthalmological complication of ATL. Authors of many reports have cited an approximately 15

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Jamie J. Van Gompel, Jesus Rubio, Gregory D. Cascino, Gregory A. Worrell, and Fredric B. Meyer

-related epilepsy is the extent to which surrounding parenchyma is resected beyond the confines of the cavernoma. 3–7 , 16–18 Although it is clear that the excision of these vascular lesions leads to good outcomes in patients with recent-onset seizures—with ~ 90% demonstrating a decrease in seizure frequency and 60–80% gaining seizure freedom 3 , 4 , 15 , 16 —it is unclear how aggressive resections should be in patients with medically refractory epilepsy. The need for more extensive surgery in patients with intractable epilepsy may be attributable to the induction of secondary

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Panagiotis Kerezoudis, Sanjeet S. Grewal, Matthew Stead, Brian Nils Lundstrom, Jeffrey W. Britton, Cheolsu Shin, Gregory D. Cascino, Benjamin H. Brinkmann, Gregory A. Worrell, and Jamie J. Van Gompel

OBJECTIVE

Epilepsy surgery is effective for lesional epilepsy, but it can be associated with significant morbidity when seizures originate from eloquent cortex that is resected. Here, the objective was to describe chronic subthreshold cortical stimulation and evaluate its early surgical safety profile in adult patients with epilepsy originating from seizure foci in cortex that is not amenable to resection.

METHODS

Adult patients with focal drug-resistant epilepsy underwent intracranial electroencephalography monitoring for evaluation of resection. Those with seizure foci in eloquent cortex were not candidates for resection and were offered a short therapeutic trial of continuous subthreshold cortical stimulation via intracranial monitoring electrodes. After a successful trial, electrodes were explanted and permanent stimulation hardware was implanted.

RESULTS

Ten patients (6 males) who underwent chronic subthreshold cortical stimulation between 2014 and 2016 were included. Based on radiographic imaging, intracranial pathologies included cortical dysplasia (n = 3), encephalomalacia (n = 3), cortical tubers (n = 1), Rasmussen encephalitis (n = 1), and linear migrational anomaly (n = 1). The duration of intracranial monitoring ranged from 3 to 20 days. All patients experienced an uneventful postoperative course and were discharged home with a median length of stay of 10 days. No postoperative surgical complications developed (median follow-up length 7.7 months). Seizure severity and seizure frequency improved in all patients.

CONCLUSIONS

The authors’ institutional experience with this small group shows that chronic subthreshold cortical stimulation can be safely and effectively performed in appropriately selected patients without postoperative complications. Future investigation will provide further insight to recently published results regarding mechanism and efficacy of this novel and promising intervention.

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Nicholas M. Wetjen, W. Richard Marsh, Fredric B. Meyer, Gregory D. Cascino, Elson So, Jeffrey W. Britton, S. Matthew Stead, and Gregory A. Worrell

P artial epilepsy represents the most common type of intractable epilepsy, and partial seizures originating from neocortex are notoriously difficult to localize and treat. 11 , 44 Presently, treatment options for patients with medically refractory epilepsy are limited to implantation of a vagus nerve stimulator, which has similar efficacy to medical therapy. 13 Epilepsy surgery has the best chance of producing a cure, that is, complete seizure freedom, but it is a viable option only if the brain region generating seizures can be accurately localized and