CHAPTER 20 epilepsy due to tbi, cvd, cns infections, and brain tumors 233 Drug-resistant tumoural epilepsy Review seizure semiology, neurological examination, MRI (high resolution, epilepsy protocol ; 1.5Telsa) Long-term video telemetry, neuropsychological and psychiatric evaluation Ictal SPECT, inter ictal PET, fMRI (if required) Discussion in patient management conference Concordant data: NON-ELOQUENT AREA LESION: Selection for surgery based on electrocortiocogr aphy Concordant data: ELOQUENT AREA LESION: Partial lesionectomy and/ or multiple subpial transe ction Inadequate/discordant data If a reasonable hypothesis can be generated Intracranial EEG monitoring; extraoperative cortical stimulation and mapping (if required) Re-discussion in patient management conference Inadequate/discordant information: Excluded from surgical candidacy Concordant data: Selection for surgery Fig. 20.6 Steps in presurgical evaluation of drug-resistant tumoural epilepsy. EEG, electro encephalography; fMRI, functional magnetic resonance imaging; HR, high- resolution; PET, po sitron emission tomography; SPECT, single-photon emission computed tomography. excision of the lesion with an adjoining rim of tissue around the lesion which is apparentl y normal on MRI. It is achieved with the aid of either prior long-term intracranial electro encephalogram monitoring or intraoperative electrocorticography. It remains a matter of con troversy whether lesionectomy alone or lesionec- tomy with excision of the surrounding epil eptogenic zone is supe- rior in terms of seizure outcome. In one series of surgical excisio ns guided by implanted subdural electrodes, it was observed that the epileptogenic zone fre quently extended beyond the con \201 nes of lesion and at many times involved non-contiguo us regions remote from the lesion. However, the postoperative seizure outcome appeared to d epend on the completeness of resection of the lesion rather than the epileptogenic zone ide nti \201 ed by mapping. When complete resection of the lesion was achieved in these patien ts, the extent of resection of the epileptogenic zone did not appear to affect postoperativ e seizure outcome ( 160 ). In certain situations, however, partial lesionectomy with a more complete epileptogenic zone resection might offer better postoperative seizure control. Th erefore, complete resection of the lesion provides the maximal likelihood of complete seizu re control following surgery but clearly, there are instances in which, carefully-planned r esection of the lesion and of the epileptogenic zone might be advantageous. 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This is of particular relevance when discussing seizures occurring in t he con- text of systemic diseases and where they should \201 t in such a classi- \201 c ation. Seizures in systemic diseases are not an inconsiderable problem, especially in the c ritically ill. The currently used terms, acute and remote symptomatic seizures (as differen tiated by the temporal relationship to the provoking factor), are confusing and probably to o simplistic as most seizures occurring in systematic disease are likely to be multifactori al, even if one cause predomi- nates. In a recently proposed aetiological classi \201 cati on of epilepsy ( 3 ), epilepsy is divided into four broad categories: idiopathic, symptomat ic, provoked, or cryptogenic epilepsy. The term \200\230pro- voked seizures \200\231 seems more appropriate for seizures in the context of systematic disease which may occur as a di rect consequence of the underlying condition, its predisposing factors, its treatment, or a combination of all three. Pathophysiology of seizures in systemic diseases Any critically ill person can develop seiz ures if the provoking stimu- lus is severe enough to lower their seizure threshold suf \201 ciently, much the same as people with epilepsy may experience an exacerba- tion in the ir seizure control in the context of concurrent illness. Nevertheless, the systemic insult required to provoke seizures is much greater in people without a prior history of epilepsy. Conditions in which seizures can occur, listed by system, are shown in Table 21.1 . Electr olyte imbalances such as sodium, glucose, calcium, magne- sium, and, rarely, low levels of potassium, can affect neuronal excitability and are important precipitants of seizures in t he criti- cally ill. Seizures as a consequence of electrolyte disturbances typi- cally occu r in the context of encephalopathy, drowsiness, headache, stupor, and other neurological sy mptoms ( 6 ). Similarly, distur- bances in the balance of neurotransmitters can predispose to sei- zures such as depletion of the inhibitory neurotransmitter gamma-aminobutyric acid or accumulation of excitatory amino acids such as glutamate and aspartate which occurs afte r hypoxic- ischaemic brain injury, leading to increased neuronal excitability and neuronal damage ( 7 ). Estimating the true frequency of seizures in people with prima- rily non-neurological condi tions is dif \201 cult as this has rarely been subject to systematic examination. Neverthe less it does seem that seizures are one of the more common neurological manifestations of s ystemic disease. In a prospective study of all admissions to a medical ITU over a 2-year pe riod, 1850 people were identi \201 ed, of whom 92 were admitted with a primary neurologica l condition. Of the remaining 1758 people, 217 (12.3 % ) developed neurological complicatio ns of which 61 (28 % ) were seizures ( 4 ). Table 21.1 Systematic conditions in which seizures are a feature Seizures arising as a consequence of systemic disease can be con- vulsive or non-convulsive , focal or generalized (either primary or secondary generalized), and particularly status e pilepticus (convul- sive and non-convulsive), the majority of which occurs in people with n o prior history of epilepsy ( 5 ). A high index of suspicion for the possibility of subtle convulsive or non-convulsive status epilep- ticus as well as the possibility of non-epilept ic seizures needs to be maintained in the critical care setting. Renal disease Uraemic encephalopathy Haemodialysis associated seizures Haemolytic uraemic s yndrome Renal transplants Dialysis disequilibrium syndrome Hepatic disease Hepatic encephalopathy Wilson \200\231s disease Liver transplants Porphyria s Respiratory conditions Neurosarcoidosis Endocrine conditions Hypothyroidism Thyrotoxicosis GLUT-1 de \201 ciency Hashimoto \200 \231s encephalopathy (SREAT) Malignant hypertension/hypertensive encephalopathy