A 24-year-old man whose focal seizures began at age 7 presented for further evaluation. During his episodes, the patient was reported as having a surprised look on his face, covering his mouth with his hands, and laughing. These episodes happened several times per day and were followed by marching movements of the legs and grunting noises. The patient had no alteration of consciousness during his seizures. He also experienced hypermotor seizures arising out of sleep at least nightly and often had several per night. The patient sustained bilateral frontal lobe damage, intraparenchymal hemorrhages, and extra axial hemorrhages following a severe fall in 2006. He was seen by several neurologists before coming to WFBH.\nThe patient’s epilepsy was refractory to multiple antiseizure medications. His initial EMU admission in 2001 was unable to localize the seizure onset zone. The interictal EEG showed very frequent epileptiform discharges arising from the right frontal region, but PET showed mild decreased activity in the left medial temporal lobe which was consistent with an epileptogenic focus. Both ictal and interictal SPECT indicated slightly asymmetric activity within the temporal lobes with the right side greater than the left, also suggestive of an epileptogenic focus within the left temporal lobe. Because of the discordant findings, the patient proceeded to invasive monitoring. ICEEG pointed towards a right frontal lobe origin, but the pattern of spiking occurred almost simultaneously with patient’s clinical semiology. At that time, it was felt that the seizure focus was not clearly localized to warrant right frontal lobectomy. The patient then received a VNS in addition to medication, and this combination was effective for several years.\nThe patient began to experience more problems around 2012 and was recommended for a MEG scan. The patient’s MEG data were very noisy owing to metal hardware in his skull that covered the burr holes from his previous invasive monitoring, but SAM(g2) sufficiently removed these artifacts and revealed a single focus in the right middle frontal gyrus (A) with numerous, MEG-only spikes (B). (Because the head is magnetically transparent, MEG is not susceptible to breach effects from craniotomies or other defects.) The MRI obtained for the MEG scan also revealed a small focus of cortical thinning and irregularity with subtle T2 hypointensity in the right frontal lobe. Based on the MEG results, the patient underwent invasive monitoring with a stereo-EEG array placed over the MEG focus (C). The patient’s epileptiform activity (green arrowhead, D) was subsequently localized to the three ICEEG contacts (green arrows) nearest to the peak of the SAM focus (red sphere, C). The patient then received a right frontal lobe resection of the seizure focus and has been seizure free since.
A 47-year-old woman with VNS implantation 10 years prior to her MEG recording presented for further evaluation. The patient reported focal seizures with evolution to bilateral convulsive seizures since childhood. The patient’s baseline EEG was notable for bilateral, independent temporal spikes. Despite multiple admissions for EMU monitoring and several captured seizures, scalp EEG demonstrated only subtle changes that were neither localizing nor lateralizing. The patient’s MRI demonstrated right mesial temporal sclerosis, bilateral polymicrogyria located around the lateral fissures, and a left hemisphere closed-lip schizencephaly. Analysis of her MEG data by SAM(g2) revealed kurtotic activity that localized to left lateral parietal cortex just above the lateral fissure and extended down into the superior temporal gyrus. Importantly, this focus overlaps with the region of schizencephaly in the left parietal cortex. The source signal series for this focus had an SNR of about 35:1, although the interictal spikes present in the MEG recording did not have a clear EEG correlate.\nGiven the findings of right mesial temporal sclerosis and the probable multifocal nature of this patient’s epilepsy, this patient received a right temporal lobectomy without invasive monitoring with the goal of seizure reduction. Prior to her surgery, the patient had two to eight focal seizures with evolution to bilateral convulsive seizures monthly, and following resection no seizures have been reported although the patient continues to have likely non-epileptic spells.