Epilepsy surgery in the elderly: an unusual case of a 75-year-old man with recurrent status epilepticus.

BACKGROUND: Epilepsy surgery is increasingly well-supported as an effective treatment for patients with intractable epilepsy. It is most often performed on younger patients and the safety and efficacy of epilepsy surgery in elderly patients are not frequently described. CASE REPORT: We report a case of a 75-year-old right-handed man who underwent a left fronto-temporal craniotomy for resection of a suprasellar meningioma in 2002. Immediately following hospital discharge, he began to experience complex partial seizures. He continued to have frequent seizures despite treatment with multiple combinations of antiepileptic medications. He presented with status epilepticus every two or three months, and required long periods of hospitalization on each occasion for post-ictal confusion and aphasia. Scalp EEG showed continuous spikes and polyspikes and persistent slowing in the left temporal area, as well as spikes in the left frontal area. EEG telemetry recorded multiple seizures, all with a clear focus in the left temporal area. MRI scan showed an area of encephalomalacia in the left temporal lobe, as well as post-surgical changes in the left frontal area. Neuropsychological testing showed bilateral memory impairment with no significant cognitive decline expected after unilateral temporal lobe resection. A left anteromesial temporal lobectomy was performed with intraoperative electrocorticography. Since surgery, the patient was not seizure-free (Engel class II-b), but had no further episodes of status epilepticus in one year and two months of follow-up. CONCLUSIONS: This is one of the oldest patients reported in the literature with epilepsy surgery and supports the possibility of epilepsy surgery in elderly patients for particular cases. In addition, few cases with such a malignant evolution of temporal lobe epilepsy have been described in this age group.

Metastatic craniopharyngioma: case report and literature review.

BACKGROUND: Distant spread of craniopharyngioma is a rare but important complication. Most cases are a result of spread along the surgical path. We describe a rare case of metastatic leptomeningeal craniopharyngioma as a result of dissemination along CSF pathways in a child. A review of previously described cases is provided. CASE PRESENTATION: A 14-year-old male was diagnosed with metastatic craniopharyngioma on routine follow-up imaging after multiple surgeries and radiation for locally recurrent craniopharyngioma. The lesion was erosive through the right parietal bone, but had remained clinically silent. The lesion was distant from previous surgical paths. The patient underwent right parietal craniotomy and resection of the lesion. Duraplasty and cranioplasty were necessary for closure. Histopathology confirmed adamantinomatous craniopharyngioma. One-year follow-up demonstrated no recurrence. DISCUSSION: A review of reported cases suggests that leptomeningeal implantation may be an important step in metastases of craniopharyngioma, although the mechanism is poorly understood. Attention to tumor spillage at the time of surgery may be important in preventing distant recurrences.

Dual energy CT at the synchrotron: a piglet model for neurovascular research.

BACKGROUND: Although the quality of imaging techniques available for neurovascular angiography in the hospital environment has significantly improved over the last decades, the equipment used for clinical work is not always suited for neurovascular research in animal models. We have previously investigated the suitability of synchrotron-based K-edge digital subtraction angiography (KEDSA) after intravenous injection of iodinated contrast agent for neurovascular angiography in radiography mode in both rabbit and pig models. We now have used the KEDSA technique for the acquisition of three-dimensional images and dual energy CT. MATERIALS AND METHODS: All experiments were conducted at the biomedical beamline ID 17 of the European Synchrotron Radiation Facility (ESRF). A solid state germanium (Ge) detector was used for the acquisition of image pairs at 33.0 and 33.3 keV. Three-dimensional images were reconstructed from an image series containing 60 single images taken throughout a full rotation of 360°. CT images were reconstructed from two half-acquisitions with 720 projections each. RESULTS: The small detector field of view was a limiting factor in our experiments. Nevertheless, we were able to show that dual energy CT using the KEDSA technique available at ID 17 is suitable for neurovascular research in animal models.

Synchrotron-based intra-venous K-edge digital subtraction angiography in a pig model: a feasibility study.

BACKGROUND: K-edge digital subtraction angiography (KEDSA) combined with the tunability of synchrotron beam yields an imaging technique that is highly sensitive to low concentrations of contrast agents. Thus, contrast agent can be administered intravenously, obviating the need for insertion of a guided catheter to deliver a bolus of contrast agent close to the target tissue. With the high-resolution detectors used at synchrotron facilities, images can be acquired at high spatial resolution. Thus, the KEDSA appears particularly suited for studies of neurovascular pathology in animal models, where the vascular diameters are significantly smaller than in human patients. MATERIALS AND METHODS: This feasibility study was designed to test the suitability of KEDSA after intravenous injection of iodine-based contrast agent for use in a pig model. Four adult male pigs were used for our experiments. Neurovascular angiographic images were acquired using KEDSA with a solid state Germanium (Ge) detector at the European Synchrotron Radiation Facility (ESRF) in Grenoble, France. RESULTS: After intravenous injection of 0.9 ml/kg iodinated contrast agent (Xenetix), the peak iodine concentrations in the internal carotid and middle cerebral arteries reached 35 mg/ml. KEDSA images in radiography mode allowed the visualization of intracranial arteries of less than 1.5mm diameter.