1. Lesional epilepsy
Dr. M.Manoranjitha kumari
Prof V.G.Ramesh‘s unit
Madras Institute Of Neurology
Chennai

2. Case
14 yr old male, 8 th std, namakkal
c/o seizures- 5 yrs duration
HOPI: apparently normal till 5 yrs ago, one day he
developed staring look, not responding to his
mother call, lasting for 1 -2mnts without any
clonic tonic movement, regained his activities
after few minutes without any post ictal
confusion , head ache, or weakness not
preceeded aura. 1 episode in a month- 3 yrs.
Started on CBZ and Levitiracetam, frequency of
seizures increased to once in 10 days- 2 yrs.

3. • For the past one month 2-3 times a day, starts as a starring
look followed by turning of head towards left side with
deviation of eye towards left side,with tonic posturing of left
hand followed by right hand, some times with clonic
movements, with loss of consciousness lasting for 1-2 mnts,
without any post ictal confusion or weakness, with or without
preceeding aura
• no head ache /vomiting/behavioural disturbances/limb
weakness/cranial nerve disturbances/trauma

4. • Past history: evaluated for epilepsy in 2004
ct plain was reported as calcified glioma,
started on AED, 2008 AED dose increased and
ct was repeated and was reported as calcified
granuloma
Antenatal natal post natal history, family history
nil relevant

5. • O/E : pt conscious, oriented
thin bult, no neurocutaneous marker
HMF: normal
Lobar functions: normal
Cranial nerves: normal
Sms : normal
Cerebellar function: normal
Spine and cranium: normal

6. CT brain
2004 2008

7. MRI
3.5*2.5*2.5*cm sized T1 &T2
hetero intense lesion noted in
the right superior middle
temporal gyrus with cortical
expansion. Calvarial
remodelling noted in the
adjacent right temporal lobe.
No evidence of diffusion
restriction in the cortical
lesion, minimal heterogenous
enhancement noted in the
lesion. Evidence of blooming
in GRE
D/D
DNET
Oligidendroglioma
Ganglioglioma

10. • EEG- normal study
• Other investigations- normal

11. Differential diagnosis
• Oligodendroglioma
• Ganglioglioma
• DNET

12. Surgery
• Right temporal craniotomy, trans cortical
approach and total excision of tumor done,
the tumor was soft, with areas of old
hemorrhages and calcification.

13. Biopsy
• Squash : tuberculoma
• HPE– suggestive of vascular tumor - angioma

14. Post opertative
• No fits after surgery
• On AED – dose is being taperd

15. Post op scan

16. Post op EEG
• Background shows well formed alpha waves in
posterior head regions, responding normally
to eye opening. Bilateral sharp waves and
spikes seen more during hyperventilation and
after hyperventilation. No slow waves seen.
• Imp : abnormal record suggestive of bilateral
epileptiform avtivity

17. What is lesional epilepsy?
• In some patients with longstanding epilepsy
the cause of the seizure may be a slow
growing tumors , vascular malformations,
infections or congenital anomalies. These
lesions are picked up in the MRI.
• Removal of the lesion may cure a patients
with epilepsy

18. Classification
• Temporal lobe epilepsy
• Extra temporal lobe lesional epilepsy
• Subcortical lesional epilepsy
• Catastrophic epilepsy

19. Temporal lobe and extra temporal
lobe lesional epilepsy
• Neoplastic- eg. Astrocytoma,
ganglioglioma,pleomorphic xanthoastrocytoma,
DNET
• Vascular-eg. Cavernous hemangioma,
arteriovenous malformation, angioma
• Dysgenetic -eg. Focal or diffuse cortical dysplasia,
sturge weber syndrome, tuberous sclerosis
• Traumatic
• Ischemic

20. Subcortical epilepsy
• Hypothalamic hamartoma
• Cerebellar seizures

21. Catastrophic epilepsy
• Hemimegalencephaly
• Diffuse cortical dysplasias
• Rasmussens
• Porencephalic cyst

22. Long term seizure control after
lesionectomy
9 years follow up of 53 patients operated for
supra tentorial cavernomas:
45 (84.9%)pts- free from disabling seizure-
Engels class1
37(69.8%)pts –completely free of post op
seizure Engels class 1A
International league against epilesy
JNS nov 2008- volume 63

23. • 22 out of 26 cases -84.6% of seizure control
after surgery for temporal lobe ganglioglima
(Morris et al)
• Complete seizure relief in12 of16
patients(75%) operated for DNET
Raymond et al

24. Predictors of seizure control after
surgery
• Lower pre op frequency of partial seizure associated with better
outcome
• Presence of CPS – supportive predictive parameters for satisfactory
seizure relief
• Secondary seizure generalization- negative predictor for seizure
control
• Because of very low rate of patients with discordant EEG patterns ,
information derived from EEG recordings is not suitable to
discriminate patients with a lower expectation of seizure control.
• Other studies found a significant contribution of EEG data in
predicting outcome after surgery especially in patients with mesial
temporal sclerosis.