Pediatric epilepsy surgery plan for 9-year-old boy with pharmacoresistant focal epilepsy

Shown is an example of multidisciplinary approach to pediatric epilepsy surgery planning in a 9-year-old boy with pharmacoresistant focal epilepsy. Location of seizures, spikes, focal slowing, and fast ripples (high-frequency oscillations at 250 to 500 Hz) were mapped in a 3D reconstructed image of patient’s MRI and grid/strip electrodes (A). Pre-operative MRI, FDG-PET/MRI (B) and actual picture from the operation room (C) were used to create the 3D reconstructed image, and resection margin was determined based on discussion among the multidisciplinary epilepsy team. An extended temporo-parieto-occipital resection was performed based on widely distributed PET hypometabolism, epileptiform discharges, and slowing, although conventional MRI showed no anatomical abnormalities. Pathology showed gliosis with minimal cortical disorganization (our clinical suspicion was cortical dysplasia type I). (Contributed by Dr. Hiroki Nariai.)