Completion Posterior Quadrant Disconnection After Failed Temporal Lobectomy: 2-Dimensional Operative Video.

Epilepsy is a chronic seizure disorder that affects about 1% of the global population.1 When seizure freedom cannot be obtained solely through antiseizure medicines (ASMs), the condition is termed medically refractory epilepsy (MRE).2,3 Though posterior quadrant disconnection (PQD) is underutilized in our experience, it is a highly effective surgical procedure for MRE restricted to the temporal, parietal, and/or occipital lobes.4-12 In this operative video, we demonstrate a right-sided completion PQD following failed temporal lobectomy in an 8-yr-old female with focal MRE. We review technical nuances, including (1) extension/revision of prior scalp incision, (2) placement of subdural strip for the identification of phase reversal and central sulcus, (3) disconnection of parietal and occipital lobes, (4) extension of the corticectomy to the pia overlying the falcotentorial junction and into the prior temporal lobectomy defect, and (5) posterior disconnection of the corpus callosum. Postoperatively, the patient experienced subtle left-arm weakness and central fever, both of which resolved. An external ventricular drain (EVD) was placed in the ventricle/operative cavity and left for 3 to 4 d until the draining cerebrospinal fluid (CSF) cleared. As of 3-mo follow-up, she has been seizure-free without complications. In summary, PQD is a safe and effective treatment option for MRE that can be utilized not only as an initial operation but also after failed surgery. Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes. Image at 4:00 licensed under CC BY-2.5, 2006, modified from http://upload.wikimedia.org/wikipedia/commons/7/70/Lateral_head_skull.jpg (flipped and rotated). Image at 4:42, Public Domain: Gray H. Anatomy of the Human Body. 1918. Bartleby.com, https://commons.wikimedia.org/wiki/File:Lobes_of_the_brain_NL.svg; flipped, modified. Image at 6:42, Public Domain: House EL, Pansky B. A Functional Approach to Neuroanatomy. 1960. McGraw-Hill Book Company; https://upload.wikimedia.wikipedia.commons/5/52/Lawrence_1960_2.3.png; modified.

Seizures from valproate-carbapenem interaction.

BACKGROUND: Antiepileptic medication interactions can complicate the management of epilepsy, by either increasing or reducing the effective serum concentrations thereby causing adverse effects or loss of seizure control. RESULTS: A 14-year-old girl with well-controlled juvenile absence epilepsy lost control of her seizures acutely following the administration of carbapenem for pneumonia. Serum valproate concentrations fell by 90% within 48 hours following carbapenem and returned to baseline following its discontinuation. CONCLUSIONS: Awareness of this clinically significant interaction alters clinical practice by avoiding carbapenem or temporary use of adjunctive medication to prevent the clinical consequences of this significant drug interaction.

Clinically significant bradyarrhythmias in video-EEG patients.

PURPOSE: The prevalence of patients thought to have epilepsy who are ultimately diagnosed with asystole or bradyarrhythmias not associated with seizures is currently unknown. We studied a tertiary referral population to determine the rate of clinically significant asystole or bradyarrhythmias in patients being evaluated for possible epilepsy in 2 inpatient epilepsy monitoring units (EMU). METHODS: A retrospective cohort of 1606 consecutive patients admitted for video-EEG monitoring at University of New Mexico Hospital from January 2000 to July 2005 and Mayo Clinic Florida from September 2005 to August 2009 was reviewed for clinical presentation and outcome of video-EEG and EKG monitoring. All patients included in the final analysis (n=1433) were admitted with a diagnosis of "possible seizures". RESULTS: The majority of subjects were under the age of 20 and 10% of subjects were over age 50. The rate of significant cardiac bradyarrhythmias was 0.3% (4/1433). Three of the four subjects with cardiac arrhythmias had symptom onset in childhood. One subject died during the evaluation. CONCLUSIONS: The rate of patients admitted for video-EEG monitoring who are ultimately diagnosed with asystole and bradyarrhythmias not associated with epilepsy is low. Symptom may begin in childhood.