ABSTRACT
Temporal lobe epilepsy (TLE) is the most common form of drug-resistant epilepsy. The main pathological changes primarily involve hippocampal sclerosis (HS). Early resective surgery of the sclerotic hippocampus is typically associated with favorable clinical outcomes. However, not all patients are suitable candidates for resective surgery of mesial temporal lobe structures. Therefore, alternative treatment modalities should be considered. We present the case of a 50-year-old right-handed woman with left HS who underwent unilateral subiculum stimulation for drug-resistant epilepsy (DRE). Since the age of 10, the patient had been experiencing focal to bilateral tonic-clonic seizures (FBTCS). Despite multiple antiseizure medications, she experienced 12 to 17 FBTCS per month in the last two years. Due to concerns about potential memory decline and personal preferences, she refused resective surgery. As an alternative, the patient underwent left unilateral subiculum stimulation. The stimulation resulted in a nearly 67 % reduction in seizure frequency at the last follow-up (20 months after surgery). This case highlights that drug-resistant epilepsy may be effectively treated with subicular stimulation in patients with HS.
ABSTRACT
Background: The intracranial lipomas are rare congenital malformations accounting for approximately 0.1-1.3% of all intracranial tumors, of which Sylvian fissure lipomas account for <5%. These lesions are frequently associated with dysgenesis of neuronal brain tissues and vascular malformations and in the majority are asymptomatic. Intracranial lipomas on magnetic resonance imaging (MRI) may mimic late subacute hemorrhage due to similar radiological features. Due to the tight adhesion of the lipoma to the surrounding nerve structures and vessels, complete removal is difficult and does not guarantee the disappearance of symptoms. Case Description: We present the case of a 42-year-old woman with chronic headaches and short-term memory impairment who was admitted to the emergency room after an out-of-hospital brain MRI with suspected ruptured right middle cerebral artery (MCA) aneurysm and late subacute intracranial hemorrhage. In the hospital, after clinical evaluation, emergency computed tomography (CT) angiography was performed, which revealed an unruptured fusiform aneurysm located in the right MCA trifurcation surrounded by an extremely hypodense lesion corresponding to fat in the right Sylvian fissure. No features of intracranial hemorrhage were present. The diagnosis of intracranial lipoma was finally confirmed after the MRI of the brain with a fat suppression sequence. Surgical treatment was not attempted, and the patient was treated conservatively with a satisfactory general outcome. Conclusion: A Sylvian fissure lipoma may be associated with a fusiform aneurysm in the MCA trifurcation. By modifying the standard MRI protocol and performing a CT scan, an intracranial lipoma can be detected and a late subacute intracranial hemorrhage can be excluded.
