How to diagnose and treat refractory epilepsy with "negative" imaging?

*Only for medical professionals to read and reference classic cases, it is worth collecting! Epilepsy, commonly known as "horn wind" or "epilepsy", is a chronic disease caused by sudden abnormal discharge of neurons in the brain, resulting in short-term brain dysfuncti.
It is estimated that the overall prevalence of epilepsy in China is 0‰, the annual incidence is 28/100,000, and the prevalence of active epilepsy with seizures within one year is
This article is a wonderful case shared by .
Song Mingyu from the Department of Neurology, Xiangya Hospital, Central South Universi.
It has an in-depth discussion on the diagnosis and treatment of refractory epilepsy with "negative" conventional imagi.
Let's take a look! First look at the case data 31-year-old married Han woman, right-hand.
The chief complaint was "episodic facial and limb twitching with disturbance of consciousness for 20 years" and was admitted to the hospital on March 1, 201History of present illness: In 1999, the face and right upper limb twitched, accompanied by screaming, and then fell to the ground with limb twitching, foaming at the mouth, eyes turned up, and confusi.
3-6 attacks per ye.
The local hospital diagnosed "epilepsy" and took oral "carbamazepine" treatment, the specific dose is unkno.
In 2013, the patient changed to take "Oxcarbazepine" 300mg, Bid + "Levetiracetam" 500mg, Bid, and the symptoms were basically the same as befo.
From 2015 to admission, the patient repeatedly experienced sudden daze, reluctance, or unconscious wandering-like movements, sometimes secondary to generalized convulsions, 0-4 times a month, each lasting a few seconds to a few minutes and then relieved on its o.
Past history, birth history, personal history, family history: No.
Physical examination, psychiatric evaluation, biochemical examination: no speci.
Head MRI, PET-CT no speci.
24h video EEG monitoring: short sharp and slow waves (mainly in the left frontotemporal lobe area), the details of the attacks are shown in Table Table 1: Number of seizures and manifestations What type of seizure? Set side? position? Seizure type: 1st seizure, one limb twitches and then tonic-clonic seizures involving the whole body with disturbance of consciousness, full name tonic-clonic seizures secondary to focal epilepsy; 2nd sleepwalking-like manifestations, consider the manifestations of automati.
Lateral: The left interictal sporadic epileptic discharges are mainly on the left si.
The initial symptoms of the attack were right facial twitching and right upper limb rigidi.

EEG at the time of the attack showed that the abnormal discharges were concentrated on the left si.

Location: frontal lobe? From the perspective of seizure symptoms, the onset of protrusions, vocalization, shouting, twitching of one side of the face and limbs, and rapid spread of discharges quickly lead to generalized seizures, which are more in line with focal seizures from the frontal lo.

Another sleepwalking episode and the analysis of EEG characteristics may be abnormal discharges involving the temporal lo.

A review of the patient's MRI and PET-CT appears to have clues, but the evidence is insufficient (Figure
Figure 1: The patient's MRI and PET-CT ask how to diagnose and treat next? Neurosurgery implanted intracranial electrodes, identified epileptogenic foci, and placed intracranial cortex + deep electrod.

Interictal period: scattered spikes can be seen, mainly in the left frontal ar.

Attack period: The left forehead is generally low in volta.

13/19 lead paci.

Can recruit to form long-range spike rhythms and cause seizur.

Frontal spine rhythms can be transmitted to the temporal floor, frontal floor and hippocamp.

During the whole process, the patient may have mild non-convulsive symptoms, such as changes in behavior, changes in speech and intonation of excitement, e.

, and a clinical attack occu.

Neurosurgery was performed to excise the epileptogenic area, including the epileptic area and the surrounding cortex that was easily ignit.

FigurePostoperative results FigurePathological results Pathological diagnosis: (left frontal lobe) cortical structure is basically normal, the area is slightly disordered, and abnormal neurons can be se.

Consider focal cortical dysplasia type l.

▌ Postoperative diagnosisFocal cortical dysplasia type lla (left frontal lob.

Symptomatic epilepsy, focal seizures secondary to generalized seizur.

▌ After follow-up, the patients regularly took oxcarbazepine 300mg, Bid; levetiracetam 500mg, B.

The patients were followed up regularly for nearly 2 years after operation, and no clinical attack occurred aga.

The patient's physical activity and verbal expression were good, and there was no obvious adverse trend in the SCL90 mental health assessme.

Review: The diagnosis of focal cortical dysplasia is more case-dependent (Table
Table 2 In addition to the pathological diagnosis, typical imaging findings are as follows:Focal cortical thickening, abnormal gyri/sulcus morphology, unclear boundary between gray and white matter, gyrus and white matter atrophy, lobe hypoplasia or atrophy,e.

Increased white matter signal on FLAIR and T2WI, decreased white matter signal on T1WI and Transmantle si.

Figure 4: How to judge whether it is symptomatic epilepsy when typical imaging findings are negative?Whether the medical history and clinical manifestations are focal seizur.

VEEG monitors abnormal discharge and its orig.

Drug refracto.

Accurately locate the extent of epileptogenic foci & complete surgical resection: head MRI: 1-3mm thin slice scan, FLAIR image, V.

Functional MRI: DTI, MRS,e.

PET-CT, M.

Intracranial electrode monitori.

Summary: At the same time, the so-called "negative" imaging findings are not necessarily true "negative", and we need clinicians to look for them careful.

With the rapid development of our imaging technology, these "negative" imaging manifestations may no longer be the same "Negativ.